Client Information and Consent (Waxing)

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Primary/Cell Number*

Area CodePhone Number

Secondary/Work Number

Area CodePhone Number

Email*

example@email.com

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*

NoYes

Are you using Retin-a, Renova, or Accutane (an oral form of Retin-a)?*

NoYes

Are you using any other skin thinning products and/or drugs?*

NoYes

If you have selected "yes" above, please indicate which ones.

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*

NoYes

Do you use a tanning bed?*

NoYes

Are you diabetic?*

NoYes

Are you currently taking medications?*

NoYes

If you have selected "yes" above, please list medications, including over the counter drugs and/or herbal supplements.

What skin products do you regularly use?

Have you ever been treated for cancer?*

NoYes

If you have selected "yes" above, please indicate when and what treatments were used.

Are you currently being treated by a medical professional for any other illness/condition?*

NoYes

If you have selected "yes" above, please provide additional information.

What is your menstrual cycle due date?

Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it has completed.

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.

I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately.

I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures. I certifiy that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, or The Spa at Tiffany's, LLC., responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Date*

Client Name (Printed)*

Signature*